Papel de la espironolactona en el tratamiento de la hipertensión arterial resistente / Role of spironolactone in the treatment of resistant hypertension

Resumen Este artículo aporta herramientas útiles para el diagnóstico y el diagnóstico diferencial de la hipertensión arterial resistente. En él, se refieren las recomendaciones de las principales guías internacionales de tratamiento respecto de las cifras meta de presión arterial, la incapacidad o falla del tratamiento triple en un amplio porcentaje de pacientes y los factores para la elección racional del cuarto agente para la institución de un tratamiento cuádruple. Esta elección se basa en la capacidad de la espironolactona -antagonista de los receptores de aldosterona- para inhibir los efectos nocivos de la aldosterona que dificultan el control de la presión arterial e incrementan el riesgo cardiovascular en un alto porcentaje de pacientes.

Abstract This article provides useful tools for the diagnosis and differential diagnosis of resistant hypertension. Here, we refer the recommendations of the main international guidelines of management respect to the target goals of the blood pressure, the failure of triple therapy in a large percentage of patients and the factors for the rational choice of the fourth agent for the institution of a quadruple therapy. This choice is based on the ability of spironolactone, antagonist of aldosterone receptors, to inhibit the deleterious effects of aldosterone that difficult the control of blood pressure and increase the cardiovascular risk in a high percentage of patients.

Efecto de los antagonistas de aldosterona en nefropatía diabética: revisión sistemática de la literatura / Systematic review of the effect of aldosterone antagonists on urinary albumin excretion in diabetic nephropathy

The beneficial effect angiotensin converting enzyme inhibitors (ACEI) and angiotensin II receptor antagonists (ARA) for diabetic nephropathy can be hampered by the phenomenon of aldosterone escape. Aldosterone antagonists such as espironolactone or epleronone could potentiate the effects of ACEI and ARA and avoid the later problem. We performed a systematic search of the literature on the effects of aldosterone antagonists on diabetic nephropathy. We searched for clinical trials and follow up studies measuring the effects of aldosterone antagonists on urinary albumin excretion among patients with diabetic nephropathy. We retrieved 1345 papers on the subject and 10 were selected for analysis. Among these, spironolactone was more effective than comparing drugs to achieve a reduction in urinary albumin excretion of approximately 30 to 40 percent. On the other hand epleronone was not superior to comparing drugs. All studies reported a modest reduction in glomerular filtration rate and an increase in serum potassium levels. In conclusion, spironolactone in doses of 25 to 100 mg/day reduces urinary albumin excretion but reduces also glomerular filtration rate and increases serum potassium levels.

Cardiac Function in Patients with Myocardial Infarction Treated with Spironolactone: A Doppler Tissue Imaging Study / 中国康复理论与实践

@#ObjectiveTo study the effects of anti-aldosterone on left ventricular function in patients with myocardial infarction. Methods130 patients with myocardial infarction were divided into anti-aldosterone group (spironolactone 20～40 mg/d + enalapril 10～20 mg/day, n=61) and control group (enalapril 10～20 mg/d, n=69). The echocardiogram and Doppler tissue imaging (DTI) were performed at enrolling time, and 6, 12 months after treatment. ResultsIn the anti-aldosterone group, the average mitral systolic wave (s) was significantly increased 6 months after treatment （P<0.05） to the enrolling time. LVEF and LVEDD improved 12 months after treatment （P<0.05）. In the control group, the average mitral systolic wave, LVEDD and LVEF did not significantly improve (P>0.05). Ratio of peak early to late diastolic filling velocity (e/a) was no significantly different between the anti-aldosterone group and the control group. ConclusionThe combination of anti-aldosterone and ACEI in patients with myocardial infarction can improve the left ventricular systolic function after 6 and 12 months, but cannot to the diastolic function.

Hipertensión arterial resistente: [revisión] / Resistant hypertension: [review]

Resistant hypertension, defined as a persistent blood pressure over 140/90 mmHg despite the use of three antihypertensive drugs including a diuretic, is unusual. The diagnosis requires ruling out initially pseudoresistance and a lack of compliance with treatment. Ambulatory blood pressure recording allow the recognition of white coat hypertension. When there is a clinical or laboratory suspicion, secondary causes of hypertension should be discarded. Excessive salt intake, the presence of concomitant diseases such as diabetes mellitus, chronic renal disease, obesity, and psychiatric conditions such as panic attacks, anxiety and depression, should also be sought. The presence of target organ damage requires a more aggressive treatment of hypertension. Recent clinical studies indicate that the administration of aldosterone antagonists as a fourth therapeutic line provides significant additional blood pressure reduction, when added to previous antihypertensive regimens in subjects with resistant hypertension. The possible blood pressure lowering effects of prolonged electrical activation of carotid baroreceptors is under investigation.

The inhibiting effect of valsartan and spironolactone on cardiac fibrosis in spontaneously hypertensive rats / 中华老年医学杂志

Objective To explore the inhibiting effect of valsartan and spironolactone on cardiac fibrosis and the expression of integrin ? 1 and fibronectin in the heart of spontaneously hypertensive rats. Methods Eighteen 6 week old SHR were randomly divided into 3 groups with 6 in each: SHR control group, valsartan treating group(30 mg?kg -1 ?d -1 ) and spironolactone treating group ( 20 mg?kg -1 ?d -1 ). Six homogenous male WKY rats served as normal group. After 14 weeks of treatment, systolic blood pressure, left ventricular mass, the ratio of left ventricular mass to body weight (LVM/BW), collagen volume fraction(CVF) and perivascular collagen area(PVCA) were determined and compared among these groups. The expression of integrin ? 1 and fibronectin were also examined by immunohistochemical method. Results Compared with the untreated SHR S, systolic blood pressure was significantly decreased in both treatment groups. LVM/BW〔(2 84?0 14)?10 -3 vs(3 22?0 15)?10 -3 〕, CVF〔(3 21?0 22)%vs(4 00?0 28)%〕, PVCA〔(0 62?0 15)%vs(0 94?0 56)%〕 were lower in both treatment groups, these parameters in SHR V group were even lower than those in SHR S group. Compared with the untreated SHR S, the expression of integrin ? 1 was significantly reduced in SHR V group, while the expression of fibronectin was markedly reduced in both treatment groups. Conclusions Both valsartan and spironolactone could control blood pressure, and effectively inhibit the cardiac fibrosis. Valsartan could also inhibit the expression of cardiac integrin ? 1 and fibronectin, which might be the reason that valsartan is better than spironolactone in inhibiting cardiac fibrosis.